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42 U.S.C. § 1320c — Purpose
Federal law — U.S. Code and appendices · legal_authorities
The purpose of this part is to establish the contracting process which the Secretary must follow pursuant to the requirements of [section 1395y(g) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395y/g&num=0&edition=prelim), including the definition of the quality improvement organizations with which the Secretary shall contract, the functions such quality improvement organizations are to perform, the confidentiality of medical records, and related administrative matters to facilitate the carrying out of the purposes of this part.
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1320c
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Source location: Title 42, Chapter 7, § 1320c; chapter-007-social-security.md
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The purpose of this part is to establish the contracting process which the Secretary must follow pursuant to the requirements of [section 1395y(g) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395y/g&num=0&edition=prelim), including the definition of the quality improvement organizations with which the Secretary shall contract, the functions such quality improvement organizations are to perform, the confidentiality of medical records, and related administrative matters to facilitate the carrying out of the purposes of this part.
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Federal law — U.S. Code and appendices · legal_authorities
**(a)** To assure that medical care is available for dependents, as described in subparagraphs (A), (D), and (I) of [section 1072(2) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title10-section1072/2&num=0&edition=prelim), of members of the uniformed services who are on active duty for a period of more than 30 days, the Secretary of Defense, after consulting with the other administering Secretaries, shall contract, under the authority of this section, for medical care for those persons under such insurance, medical service, or health plans as he considers appropriate. The types of health care authorized under this section shall be the same as those provided under [section 1076 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title10-section1076&num=0&edition=prelim), except as follows:
(1) With respect to dental care—
(A) except as provided in subparagraph (B), only that care required as a necessary adjunct to medical or surgical treatment may be provided; and
(B) in connection with dental treatment for patients with developmental, mental, or physical disabilities or for pediatric patients age 5 or under, only institutional and anesthesia services may be provided.
(2) Consistent with such regulations as the Secretary of Defense may prescribe regarding the content of health promotion and disease prevention visits, the schedule and method of cervical cancer screenings and breast cancer screenings, the schedule and method of colon and prostate cancer screenings, and the types and schedule of immunizations—
(A) for dependents under six years of age, both health promotion and disease prevention visits and immunizations may be provided; and
(B) for dependents six years of age or older, health promotion an
Source: Supplied U.S. Code snapshot — release unconfirmed · 10 U.S.C. § 1079
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Federal law — U.S. Code and appendices · legal_authorities
This chapter may be cited as the “Social Security Act”.
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1305
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Federal law — U.S. Code and appendices · legal_authorities
The term “quality improvement organization” means an entity which—
(1) is able, as determined by the Secretary, to perform its functions under this part in a manner consistent with the efficient and effective administration of this part and subchapter XVIII;
(2) has at least one individual who is a representative of health care providers on its governing body; and
(3) has at least one individual who is a representative of consumers on its governing body.
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1320c–1
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Federal law — U.S. Code and appendices · legal_authorities
The Secretary shall submit to the Congress not later than April 1 of each year, a full and complete report on the administration, impact, and cost of the program under this part during the preceding fiscal year, including data and information on—
(1) the number, status, and service areas of all quality improvement organizations participating in the program;
(2) the number of health care institutions and practitioners whose services are subject to review by such organizations, and the number of beneficiaries and recipients who received services subject to such review during such year;
(3) the various methods of reimbursement utilized in contracts under this part, and the relative efficiency of each such method of reimbursement;
(4) the imposition of penalties and sanctions under this title for violations of law and for failure to comply with the obligations imposed by this part;
(5) the total costs incurred under subchapters XVIII and XIX of this chapter in the implementation and operation of all procedures required by such subchapters for the review of services to determine their medical necessity, appropriateness of use, and quality; and
(6) descriptions of the criteria upon which decisions are made, and the selection and relative weights of such criteria.
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1320c–10
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Federal law — U.S. Code and appendices · legal_authorities
**(a) Establishment of geographic areas** The Secretary shall establish throughout the United States such local, State, regional, national, or other geographic areas as the Secretary determines appropriate with respect to which contracts under this part will be made.
**(b) Organizations entitled to contract with Secretary**
(1) The Secretary shall enter into contracts with one or more quality improvement organizations for each area established under subsection (a) if a qualified organization is available in such area and such organization and the Secretary have negotiated a proposed contract which the Secretary determines will be carried out by such organization in a manner consistent with the efficient and effective administration of this part. In entering into contracts with such qualified organizations, the Secretary shall, to the extent appropriate, seek to ensure that each of the functions described in [section 1320c–3(a) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1320c–3/a&num=0&edition=prelim) are carried out within an area established under subsection (a). If more than one such qualified organization will be operating in an area, the Secretary shall ensure that there is no duplication of the functions carried out by such organizations within the area.
(2)
(A) Prior to November 15, 1984, the Secretary shall not enter into a contract under this part with any entity which is, or is affiliated with (through management, ownership, or common control), an entity (other than a self-insured employer) which directly or indirectly makes payments to any practitioner or provider whose health care services are reviewed by such entity or would be reviewed by such entity if it entered into a contract with the Secretary under
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1320c–2
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Federal law — U.S. Code and appendices · legal_authorities
**(a) Review of professional activities; determination of payment; determination of review authority; consultation with professional health care practitioners; standards of health care; other duties** Subject to subsection (b), any quality improvement organization entering into a contract with the Secretary under this part must perform one or more of the following functions:
(1) The organization shall review some or all of the professional activities in the area, subject to the terms of the contract and subject to the requirements of subsection (d), of physicians and other health care practitioners and institutional and noninstitutional providers of health care services in the provision of health care services and items for which payment may be made (in whole or in part) under subchapter XVIII (including where payment is made for such services to eligible organizations pursuant to contracts under [section 1395mm of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395mm&num=0&edition=prelim), to Medicare Advantage organizations pursuant to contracts under part C, and to prescription drug sponsors pursuant to contracts under part D) for the purpose of determining whether—
(A) such services and items are or were reasonable and medically necessary and whether such services and items are not allowable under subsection (a)(1) or (a)(9) of [section 1395y of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395y&num=0&edition=prelim);
(B) the quality of such services meets professionally recognized standards of health care; and
(C) in case such services and items are proposed to be provided in a hospital or other health care facility on an inpatient basis, such services and items could, con
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1320c–3
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Federal law — U.S. Code and appendices · legal_authorities
Any beneficiary who is entitled to benefits under subchapter XVIII, and, subject to [section 1320c–3(a)(3)(D) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1320c–3/a/3/D&num=0&edition=prelim), any practitioner or provider, who is dissatisfied with a determination made by a contracting quality improvement organization in conducting its review responsibilities under this part, shall be entitled to a reconsideration of such determination by the reviewing organization. Where the reconsideration is adverse to the beneficiary and where the matter in controversy is $200 or more, such beneficiary shall be entitled to a hearing by the Secretary (to the same extent as beneficiaries under subchapter II are entitled to a hearing by the Commissioner of Social Security under [section 405(b) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section405/b&num=0&edition=prelim)). For purposes of the preceding sentence, subsection (l) of [section 405 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section405&num=0&edition=prelim) shall apply, except that any reference in such subsection to the Commissioner of Social Security or the Social Security Administration shall be deemed a reference to the Secretary or the Department of Health and Human Services, respectively. Where the amount in controversy is $2,000 or more, such beneficiary shall be entitled to judicial review of any final decision relating to a reconsideration described in this subsection.
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1320c–4
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Federal law — U.S. Code and appendices · legal_authorities
**(a) Assurances regarding services and items ordered or provided by practitioner or provider** It shall be the obligation of any health care practitioner and any other person (including a hospital or other health care facility, organization, or agency) who provides health care services for which payment may be made (in whole or in part) under this chapter, to assure, to the extent of his authority that services or items ordered or provided by such practitioner or person to beneficiaries and recipients under this chapter—
(1) will be provided economically and only when, and to the extent, medically necessary;
(2) will be of a quality which meets professionally recognized standards of health care; and
(3) will be supported by evidence of medical necessity and quality in such form and fashion and at such time as may reasonably be required by a reviewing quality improvement organization in the exercise of its duties and responsibilities.
**(b) Sanctions and penalties; hearings and review**
(1) If after reasonable notice and opportunity for discussion with the practitioner or person concerned, and, if appropriate, after the practitioner or person has been given a reasonable opportunity to enter into and complete a corrective action plan (which may include remedial education) agreed to by the organization, and has failed successfully to complete such plan, any organization having a contract with the Secretary under this part determines that such practitioner or person has—
(A) failed in a substantial number of cases substantially to comply with any obligation imposed on him under subsection (a), or
(B) grossly and flagrantly violated any such obligation in one or more instances,
such organization shall submit a report and recommendations to the Secretary. If the
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1320c–5
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Federal law — U.S. Code and appendices · legal_authorities
**(a) State plan provision that functions of quality improvement organizations may be performed by contract with such organization** A State plan approved under subchapter XIX of this chapter may provide that the functions specified in [section 1320c–3 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1320c-3&num=0&edition=prelim) may be performed in an area by contract with a quality improvement organization that has entered into a contract with the Secretary in accordance with the provisions of [section 1395y(g) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395y/g&num=0&edition=prelim).
**(b) Federal share of expenditures** In the event a State enters into a contract in accordance with subsection (a), the Federal share of the expenditures made to the contracting organization for its costs in the performance of its functions under the State plan shall be 75 percent (as provided in [section 1396b(a)(3)(C) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1396b/a/3/C&num=0&edition=prelim)).
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1320c–7
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Federal law — U.S. Code and appendices · legal_authorities
**(a) Freedom of Information Act inapplicable; exceptions to nondisclosure** An organization, in carrying out its functions under a contract entered into under this part, shall not be a Federal agency for purposes of the provisions of [section 552 of title 5](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title5-section552&num=0&edition=prelim) (commonly referred to as the Freedom of Information Act). Any data or information acquired by any such organization in the exercise of its duties and functions shall be held in confidence and shall not be disclosed to any person except—
(1) to the extent that may be necessary to carry out the purposes of this part,
(2) in such cases and under such circumstances as the Secretary shall by regulations provide to assure adequate protection of the rights and interests of patients, health care practitioners, or providers of health care, or
(3) in accordance with subsection (b).
**(b) Disclosure of information permitted** An organization having a contract with the Secretary under this part shall provide in accordance with procedures and safeguards established by the Secretary, data and information—
(1) which may identify specific providers or practitioners as may be necessary—
(A) to assist Federal and State agencies recognized by the Secretary as having responsibility for identifying and investigating cases or patterns of fraud or abuse, which data and information shall be provided by the quality improvement organization to any such agency at the request of such agency relating to a specific case or pattern;
(B) to assist appropriate Federal and State agencies recognized by the Secretary as having responsibility for identifying cases or patterns involving risks to the public health, which data and information s
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1320c–9
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